Seizing the momentum for reform in Primary Care

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Frank Vandenbroucke

Vice-Prime Minister and Minister of Social Affairs and Public Health (Belgium)

28th WONCA conference, 6 June 2023

Thank you for your generous introduction.

Ladies and gentlemen, I don't know about you, but I always feel a little saddened when I have to speak after such beautiful music. But I will speak about health.

Health is what exercises you, everyday. The health of your patients, but also - and we need to make this a real priority - the health of the general public. Public health, to put it simply.

COVID, indeed, made us face the facts in this way, in no uncertain terms. This tiny little virus caused healthcare systems to nearly collapse in many countries, but also made them innovate and transform themselves.

We have seen stress and hardship, but also unprecedented collaboration and creativity.

We have seen a shift to population-level management.

We have seen a true focus on public health, in the form of tracing, testing and vaccination.

An accelerated roll-out of digital care in the form of telemonitoring and remote consultations.

And we have also seen that traditional funding models such as fee-for-service, fail to adequately meet these new challenges.

We have also seen that solidarity and the organization of solidarity are of the essence if you need to weather such a crisis.


The European Observatory on Health Systems and Policies issued a report, ‘Health Systems Resilience during COVID-19 - lessons for building back better’, which identifies 20 key strategies to improve our healthcare systems resilience. They are divided into five strategic strands.

The first is about leading and governing; about political leadership and the importance of civil society, as well as about monitoring, data, scientific inputs, clear communication and transparency.

The second strand is about stable funding and extra investment, not only to meet existing needs, but also to address vulnerable groups and changing needs, and to get the funding incentives right.

The third strand identified by the European Observatory is about mobilizing and supporting the health work force through a good HR policy: not only to have the necessary staff, to have the right person in the right place and to provide each of them with adequate support; but also to solidify the unprecedented creativity of our health care work force which we have seen during COVID.

The fourth strand is about reinforcing public health interventions so that our health systems can both respond to an unexpected pandemic but also, simultaneously, to guarantee ‘ongoing work’, business as usual, if I may put it that way.

And finally, the fifth strand highlighted by the European Observatory is about transforming our systems, by focusing on new care pathways, innovation and reinforcing primary care.


These aren't exactly new ideas, but I'm convinced that COVID has underscored their urgency and bolstered support for them.

Indeed, the COVID-19 pandemic presented a specific challenge to primary care, to its organization, the people working in it and its interfaces with the wider healthcare system.

The fight against COVID has emphasized the critical role of primary care within the healthcare system, serving as the first and, for most patients, the only point of contact with healthcare professionals.

During the pandemic, general practitioners had extensive responsibilities for providing care for COVID-19 patients, including severely ill patients who were not hospitalized due to a lack of hospital beds. Treating patients with post-COVID consequences, providing ongoing care for non-COVID patients, contributing to public health services notably in vaccination programs, and also acting as a source of trust, a reference for all worried citizens.

During the COVID-19 pandemic, a consortium of 48 research institutions, in collaboration with EQuiP, rolled out the PRICOV-19 study. This study analyzed how GP practices in 38 countries adapted themselves to provide safe, effective, timely, person-centered, and equitable care during the pandemic.

The scale and international design of PRICOV-19 allows to identify areas and strategies for improvement, to better prepare for the future.

The conclusions of this study are a must-read. They are in line with the five strategic strands outlined by the European Observatory. They demonstrate the importance of well-developed interprofessional GP practices for pandemic preparedness, most of all because of their agility and their impact on health inequalities.


Ladies and gentlemen, our care systems are obviously very different across the world. But the fundamental diagnosis is mostly similar. We're all facing the same multifaceted set of challenges: an aging population and also an aging healthcare workforce; the increase in chronic illness and morbidity, changing care demands, and patient emancipation; the need for more healthcare staff and to some extent a different healthcare staff, but also job shortages, technological developments and innovation.

Fundamentally, against the backdrop of the Quintuple Aim, we must bring about a paradigm shift from disease-oriented to goal-oriented care, whereby the care process aims to achieve the patient's life goals and population health perspective, all this based on integrated care.

Now, obviously, as a policy maker, I’m very aware that public resources are scarce while the needs are seemingly endless. This might lead us to focus very much on efficiency, which is not wrong per se. However, it’s not happenstance that I mentioned the Quintuple Aim: efficiency is only one of the elements of the Quintuple Aim. Given the many challenges we face, it is also crucial to invest sufficiently in healthcare. That is what we try to do, at least in this country, with a real growth norm of 2.5% per year for federal-level health care spending, and many additional initiatives.


Yet, even with this expansive budget, one cannot assume that all needs can be met. Such an expanding budget certainly offers real policy choices, which is what it should do. But the coalition agreement of the current federal government also stipulates that the increased budget should not only serve to cover new demands for care; it should also be used to trigger reform. In our country, if I may elaborate a little bit on that, this confronts us with two specific but key governance challenges.

First of all, traditionally in Belgium, health insurance budgets are distributed in a game of giving and taking between healthcare providers and health insurance funds. What exercises them very much in these negotiations is the distribution of resources across sectors, and, to be honest, the revenue of healthcare providers across and within sectors, rather than public health priorities. Consequently, short-term goals tend to prevail over long-term vision.

We must change that mindset, moving away from short-term goals and a silo mentality towards shared health and healthcare goals based on the Quintuple Aim.

I’m now introducing, in a pragmatic way, amendments in the way in which the federal health care system is governed and its yearly budget is established, in order to change that mindset. Although pragmatic, these amendments and the change in mindset are absolutely fundamental.

Secondly, integrated care. We are a relatively complex, multi-tiered country; nobody is the boss. However complicated our political constitution, we do need integrated care for our citizens.

I’m absolutely convinced that this can be achieved, even in a complicated, multi-tiered country. But then you need clarity everywhere, on all levels, about the key building blocks of integrated care. That is the reason why I launched the idea to develop an interfederal plan for integrated care, on which we are working together with the regions and all the entities involved in health and health care in this country.

Five key building blocks should be discussed in this context:

  • What do we exactly mean by ‘coordination of care’ on the one hand, and ‘case management’ on the other hand? What is the common grammar we use when we talk about these concepts?
  • The same holds for ‘interdisciplinary work’
  • How should we organize integrated care at the meso-level? (When I say meso-level, I refer to a territorially defined population of, say, several hundred thousands of people.)
  • How can digitalization facilitate and support all this?
  • How can funding facilitate and support all this?

We need collaboration at multiple levels, and therefore we need clarity about these building blocks and a truly systemic approach.

In our country, Belgium, the challenge of achieving integrated care is very much about the relationship between health care and social care, because different governments are responsible for health care and social care. But is also about strengthening the relationship between individual and community care. It is about bolstering primary care but also about partnerships between first-line, second-line and third-line care. And, also, about partnerships between mental health care and somatic health care. Finally, it is also about the partnership between patients and healthcare professionals.

This interfederal plan for integrated care implies an ambitious agenda, which I hope to wrap up at the latest by June of next year. It is ambitious, but it is also the necessary framework within which healthcare providers can work together and use their diverse expertise to the best of their ability.


Let me illustrate the challenge with just two examples of reforms that we are initiating in Belgium.

The first is about primary mental healthcare.

We are now investing heavily in accessible and affordable primary mental health care.

But this should not be simply about integrating clinical psychologists into the traditional fee-for-service system and the traditionally purely individual relationships between the caregiver and the patient on which fee-for-service is based. No, we should promote Stepped Care models where local networks take the reins and are in charge of budgets that have to serve the needs of a population for which the mental health network is responsible. Based on their expertise and analysis of local care needs, these networks should focus on early detection, outreaching and the right approach for the right patient with integrated multidisciplinary primary care. Departing from a sole focus on the individual caregiver-patient relationship means that they have to invest in innovative methods such as group sessions. Outreaching should mean that care really comes to the patient, not the other way around. Our networks have to bring together the right actors, so that they can reinforce each other by working together rather than side by side.

Primary mental healthcare should not be just about the patients. It’s also about supporting and thus strengthening general practitioners in dealing with their patients with mental health problems.

General practitioners can for example be assisted by a psychologist during consultations with their patients. Or they can be supported by a psychologist in how to deal with signs of mental problems. Ultimately, this is also about their own professional satisfaction and mental well-being. So when we will invest massively in primary mental healthcare in this country, we also ask for a thorough paradigm shift in how we organize care, which implies a true cultural revolution.

Let me give the second example which about the organization of our general practitioners, to whom we propose a ‘New Deal’.

The organization of general practitioners has evolved significantly over the past 20 years in our country. It is fair to say that about 20 – 25 years ago, general practitioners were confronted with a looming, existential crisis of the first-line.

Family doctors often worked on their own. They worked within the walls of their own practice, and they worked very hard. Nevertheless, people tended to go more and more directly to the second-line, they tended to go more and more directly to hospitals, without referral.

The family doctor became really undervalued, in terms of both status and income. This was counterproductive with a view to adequate patient care. It was moreover the worst possible preparation in view of an aging population, which we, already then, could see on our horizon.

Twenty years ago – I had the privilege to be the minister of Health and Social affairs, and I was able to intervene, based on excellent work within the profession of general practitioners group and with their support. We were able not only to invest significantly in primary care but also to change its shape and future. We introduced forms of payment other than just the traditional fee-for-service, through the large-scale promotion of what we call the ‘Global Medical Record’ in this country. We also invested in the scientific backing of general practitioners, in electronic communication and in partnerships with other disciplines, such as home nurses and, in a later stage, pharmacists. This has allowed a renewed primary care system to develop, which is less focused on curing conditions that are by definition not curable and much more successful in providing chronic care to people, for the best possible quality of life.

Today, we see the positive impact of these reforms, launched 20 years ago, enhanced by organizational initiatives taken at the Flemish regional level more recently (the ‘first-line zones’). However, we should not be complacent. Over the last two years I became convinced that we need a new momentum of change for our general practitioners. Not only because the impact of aging will make itself felt much more strongly over the next few years, reflecting an underlying sociodemographic trend that will not come to a halt over the next 10 to 15 years. Ageing is a challenge both at the demand and the supply side of health care, but we are also witnessing other important dynamics at the supply side of healthcare, which makes the profession look pretty different from what it was 20 years ago: the digital revolution, with remote consultation, telemonitoring, the electronic patient record… In addition, there is also an increasing focus on a good work-life balance with general practitioners and the emancipation of the patient.


All this requires a multi-faceted approach to make the practice of family doctors sustainable for the future.

This is partly about fighting shortages by increasing the numbers. That is also what we have to do. But it’s also a question of improving the division of labor, strengthening the organization of practices, collaboration, new forms of care and funding. That is what the next wave of reform is about.

I will not go into the whole debate on the future of general practitioners. It is also about pointless administrative burdens that must be cut down, and other specific problems. I will focus here on the need for an improved organization which enables a general practitioner to not only care for more people but also to care for more people in a better way. Based on task delegation and support and a re-balanced funding model that can better address availability, intra- and interdisciplinary collaboration, continuity of care, prevention and empowerment.


Both the organization model and the funding, which are interrelated issues, should seek to strike the right balance between rewarding availability on the one hand and immediate responsiveness vis-à-vis the patient on the other.

Secondly, they should seek to strike the right balance between preventive follow-up, follow-up of existing conditions, and follow-up of urgent problems. They should be committed to continuity of care and a development of a therapeutic relationship of trust between doctor and patient. They should set the right incentives to prevent both over- and underconsumption.

Finally, they should promote multidisciplinary collaboration and population management.

I commissioned a reflection group led by the professors Ann Van den Bruel and Jean-Luc Belche to rethink both the organization and the funding of today's general practice in Belgium.

The reflection group was deliberately diverse in composition, including young doctors, female doctors, and obviously academics. And there was a broad bottom-up input, collected by polling the profession in the field.

I’m very grateful to Ann Van den Bruel and Jean-Luc Belche: working very hard in a time frame of just six months, they provided answers to some pretty fundamental questions:

  • What is exactly expected from a general practitioner today?
  • How should the relationship with a patient be developed in the future?
  • What kind of profiles should be in place for this process?
  • What kind of funding model will best address this?

The reflection group managed to complete this really participatory but also scholarly work in this tight time frame. The report was ready in March, and we are now finalizing the proposal on the basis of negotiations within the profession. The idea is to offer, as an opt-in, i.e. on a voluntary basis, a new model, which we call the New Deal.

The New Deal model is, in a sense, in between to juxtaposed models which we already have. On the one hand, we have many general practitioners working in an environment that is predominantly, although not completely, based on fee-for-service. On the other hand, we have the so-called ‘medical houses’ which are based on capitation, that is a (differentiated) lump sum per patient. We propose, on a voluntary basis, to opt in in a third way, in between those two relatively ‘extreme’ existing models.

The New Deal General Medical Practice should deliver an ambitious care package and be the first point of contact for a wide range of health issues with a focus on collaboration, task delegation, prevention, and continuity of care.

The funding model should support this. Today, 77% of a Belgian general practitioner’s typical income is generated by billing for consultations, visits, and technical examinations, in essence fee-for-service. The global medical record generates a capitation funding because the doctor receives a fixed amount for the follow-up of their patients through the global medical record. The global medical record generates 17% of the average Belgian general practitioner income, and the remaining 7% of the income is generated by various other fees.

One might say that this funding model has been adequate over the last 10 years. But it does not sufficiently encourage collaboration and task delegation for proactive and preventive patient follow-up. The suggestion from the working group on the New Deal is that the ratio of fee-for-service on the one hand and capitation funding on the other hand be balanced so that both account for, say, 40 to 45% of the general practitioners income.

First, this should allow the recognition of the doctor’s work outside of direct patient contacts, e.g. for complex, multidisciplinary consultations with second-line or other first-line players, team discussions of complex cases, etc.

Secondly, such a balance should allow the doctor to delegate tasks within the practice, such as assessing whether a patient who is ringing the practice, needs to see the doctor himself straight away or not. It is not only about taking over administrative tasks, the ambition is also to stimulate the delegation of simple care or preventive follow-up: work that should not always be done by the doctor herself or himself.

In addition to this balance between fee-for-service and capitation a third source of funding is proposed, an operational budget to fund the management of such practices, which should constitute about 10 to 20% of the income. It should guarantee the quality of the organization, the quality of the support, and the availability and the cooperation of all the staff involved. Thus, the overall funding needed to sustain a multidisciplinary practice would become much more stable.

We are not yet done with this reform, but what is on the table is a very good start. We must not only commit to more general practitioners in the future but to a different way of working, with the right care being provided in the right place by the right person.

Thus, we should not only increase the quality and accessibility of care for the patient but also your professional satisfaction.


Ladies and gentlemen,

I have given two examples of where we are working on: primary mental healthcare and this New Deal for general practitioners.

The challenge is broad, and the choices we have to make can be difficult indeed. Change breeds resistance; otherwise, it’s not true change.

But I've also learned from COVID that the commitments, the resilience of our caregivers can be immense. And we should build on this positivism.

Policies should support this, starting with a shared value framework with the necessary investments, based on scientific evidence, driven driven by good governance, and focused on sustainable reform. This is also very high on the agenda of your 28th conference.

I therefore wish you much success with this ambitious conference and I look forward to seeing the results.

Thank you so much.